The SKY Shade of Blue

BY MARK SCHOLZ, MD

The worst mistakes are to believe that prostate cancer is just one disease and that it will always need treatment. The entire physician community has stumbled into this terrible blunder by assuming that every tiny little spec of cancer being found through needle biopsy is equivalent to the long-familiar, deadly metastatic variety.  It was the invention of the spring-loaded needle biopsy gun, not just the discovery of PSA that launched the modern prostate cancer industry as we know it today.

Tragically, over the last twenty years, millions of men have had their sex lives ruined by unnecessary surgery or radiation. Only recently has it come to light that the Gleason six type of prostate cancer is harmless, that it never metastasizes.

Yet to this day, practically all men with Gleason six are still being treated. Justification is that since it’s called “cancer” we need to be safe and remove the gland. While many men and their doctors continue making this tragic mistake, now that we know how to differentiate between the harmless and dangerous types of prostate cancer, you can be spared.

Blue is the color for prostate cancer as pink is the color for breast cancer. So the PCRI has labeled the major subtypes of prostate cancer with different Shades of Blue. The five shades are Sky, Teal, Azure, Indigo and Royal.

Sky is the first and most favorable shade of blue, the type that can be safely monitored without treatment. Men in the Sky shade category are defined by having the following four characteristics:

1.       A PSA less than 10

2.       A Gleason score under 7

3.       A tiny nodule on digital rectal or no nodule at all

4.       Color Doppler ultrasound or multiparametric MRI scans showing no extra-capsular extension

Treatment for Sky

Studies show that initial observation, termed Active Surveillance, is a safe way to manage favorable forms of prostate cancer like Sky. In a ten-year observational study at Johns Hopkins out of1,000 carefully selected men it was reported that not a single man died of prostate cancer.  In fact there was not even a single case of metastasis.

Observation is preferred because even with the most skilled doctors, standard therapy with surgery or radiation is frequently associated with permanent impotence and incontinence.

A typical Active Surveillance program consists of PSA testing three or four times a year, a digital rectal examination once or twice a year, and periodic random prostate biopsy every one to three years. Bone scanning is not recommended.

Recently, the policy of performing routine random biopsies is being reconsidered. Biopsy is unpleasant and can occasionally be dangerous. Certain centers, those with access to quality imaging, are substituting an annual multi-parametric MRI or color Doppler ultrasound.  Biopsy is reserved only for the men whose imaging shows a new or growing lesion in the prostate. And rather than doing 12-core random biopsy, one to two targeted cores are used.       

|+| Dr. Scholz will be periodically emailing regarding the topics of Imaging, Active Surveillance, the dangers of prostate biopsy and the existence of safe alternatives.

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In Praise of Olive Oil & Avocados

BY RALPH BLUM

Nearly 2.5 million men in the United States currently live with prostate cancer, and a recent study led by UC San Francisco has found that these men may significantly improve their survival potential with a simple change in their diet.

The study, involving some 4,600 men who had been diagnosed with non-metastatic prostate cancer, found that by substituting healthy vegetable fats—olive and canola oils, nuts, seeds and avocados—for animal fats and carbohydrates, the majority of the men in the study lowered their risk of disease progression.

In the June 10, 2013 online issue of JAMA Internal Medicine, lead author Erin L. Richman, ScD, a post-doctoral scholar in the UCSF Department of Epidemiology  and Biostatistics wrote, “Consumption of healthy oils and nuts increases plasma antioxidants and reduces insulin and inflammation which may deter prostate cancer progression.”

In our book, Invasion of the Prostate Snatchers, Mark put the spotlight on insulin in a chapter entitled, The Insulin Connection. In it he explains that insulin deficiency inhibits the development and progression of cancer. However, even more significant, Mark pointed out that excess insulin in the blood acts as high-octane fuel for cancer growth, and is associated with the development of more aggressive forms of prostate cancer.

Dean Ornish, MD, of cardiac management fame, studied 93 men with prostate cancer.  Half of these men were randomly allocated to the Ornish diet program, while the remainder served as a non-treated comparison group. After twelve months, the men on the program had a statistically significant reduction in their PSA levels. Furthermore, extracting serum from the blood of men in both groups, Ornish fed it to prostate cancer cells kept alive in Petri dishes.  The cancer cells that were fed serum from the men not on his program grew eight times faster than those cells receiving serum from men who were on the program.

 

Returning to the “fat intake” study, the authors also uncovered a striking benefit: Men who replaced only 10 percent of their total daily calories from carbohydrates with healthy vegetable fats, had a 29 percent lower risk of developing lethal prostate cancer. Ornish’s dietary recommendations were simple enough: a diet that was vegan or vegetarian, non-diary, supplemented with anti-oxydents such as lycopene, selenium and vitamin E, supported by  moderate aerobic or other exercise.

Clearly further research is needed. There is rather too much “may improve,” and “may lower the risk” in many of the existing studies on the role of diet in the treatment of prostate cancer for my taste. However for now, guys, following a heart-healthy diet seems to be the safest way to go if you want to keep your cancer in check.

 So I say bring on the olive oil and avocados!

The 2013 PCRI Conference, How to Handle So Much New Information

MARK SCHOLZ, MD

Every year, it seems, the enthusiasm and excitement at the conference grows. Why?  Certainly Dr. Mark Moyad who moderates the conference, and the PCRI staff and I, who organize it, have grown from our experiences over the years. We are fine tuning and improving the agenda over time. But this isn’t the primary reason.

The prostate cancer world is changing, and changing quickly.  In the early years of putting a conference agenda together, I used to spend a lot of time “scrounging around the basement” to find content with high enough quality for presentation.  Back then the main treatments for early and advanced prostate cancer were surgery and chemotherapy respectively. Now for these same stages we have active surveillance and immunotherapy.

So the problem now – it is insufficient to do justice to all the new information in a two day conference. Nathan Roundy, one of our helpline volunteers, who recently returned to the PCRI from sabbatical, came up to me after the conference and said, “I can’t believe how much things have changed in just the last six months!”

The introductory comments I wrote in the conference syllabus convey some of these same thoughts about how the PCRI handles the massive overload of new information:

“Knowledge is power. And what you don’t know can indeed hurt you.  However, in this modern information age, the deluge of unfiltered data can be completely overwhelming. How can patients without professional training sort through it all out and distil a sensible plan of action?” 

No one can offer an easy solution.  The prostate cancer world is complex, and there are too many behind-the-scenes conflicts of interest to simply trust the first smiling doctor you encounter.  Although you can’t escape from the responsibility of doing your homework, you can make sure that you are registered ‘in the right classroom.’ 

The field of prostate cancer is vast, so the PCRI breaks the disease down into different categories, which we have termed Shades of Blue.  Failing to recognize the different Shades of prostate cancer is like wandering randomly between classrooms teaching totally different subjects. Is it any wonder there is so much confusion? Patients don’t need more information. They need personalized information—unbiased resources that are tailored to their specific disease category.”

Even though cancer is a serious subject, we had a lot of fun as well.  Ryan O’Neal came and shared his personal experience of having undergone focal cryotherapy with Dr. Duke Bahn. Dr. Mark Moyad and Ryan had a hilarious exchange culminating with Ryan giving Mark a kiss on the cheek.  Jerry Peters, our Grammy Award winning board member, along with his twelve-piece band, hosted a rocking evening at our Gala dinner Saturday night. Dr. David Hung, the CEO of Medivation, the manufacturer of Xtandi, gave a strikingly inspirational presentation concerning the acceleration of new drug development in the pharmaceutical world.

What a wonderful problem to have - with so many brand new treatments it’s hard to do justice to them in a two day conference.  The key is to recognize your shade of prostate cancer, identify the treatment options available based on that shade, and follow up with more research about those options.  The PCRI website is presently going through a major upgrade and will go live in the next week or so.  Check out www.pcri.org when you get a chance.

Apparently The Jury Is Still Out

RALPH BLUM

The  duration of the Intensity Modulated Radiation Therapy was long, and I embarked on it with no guarantees, but from the start I have expected the best. And so far, I am getting a good outcome. Only problem:  It’s far from over.

 

It is more than a month since I completed my 45^th IMRT session. What’s called for now? Another color Doppler ultrasound by Duke Bahn, MD, will show how much the cancer is diminished. Add another PSA and that should be the completion of IMRT.

 

I admit that I am getting kind of excited. Still, it is part of my self-protection policy not to expect miracles. The truth is, Dr. Chaiken never made any promises regarding a number of my concerns: What can I make of the shrinking PSA readings? What can I expect regarding tumor size? Do I dare think in terms of a “cure?”

 

And what about blood flow feeding the cancer cells? We have Bahn’s color Doppler results going back almost two decades. The last set of images showed massive blood flow to the tumors. So my first step will be to start  with the Duke.

 

The drive to Dr. Bahn’s office in Ventura seems longer than ever. Finally, we get to Brent Street, to the Prostate Institute of America.  We get started right away and I am, butt-hole lubricated to receive the ultrasound probe while lying on my left side, facing the Duke’s ultrasound screen.

 

Both Jeanne and he are seated behind me. And there on the screen are the color Doppler pictures revealing the status of Blum’s prostate: the dark shadow which is the tumor, and most telling, the red threads indicating blood flow to the tumor—the cancer’s lifeline and nutrient source.

 

As always, Dr. Bahn is very quiet and meticulous, taking what seems to me like a long time to analyze the images. Jeanne asks about the seminal vesicle, and Duke replies, “It’s not an issue anymore.” He doesn’t explain; we don’t ask. Mostly I keep my eyes closed, but when I open them I catch small adjustments on the screen. It seems to take forever. Then, out slides the probe. He says, “We’re done,” and scurries off to his office while I wipe away the jelly and dress, wondering: Will this be my last color Doppler ultrasound?

 

The Duke does his write-up, and then shows me the last color Doppler. Although he tends to be mild-mannered and unexcitable, I catch a thread of—what? Enthusiasm, perhaps, in his voice? He seems pleased with the results.

 

“Over 80 percent, gone. What we call apoptosis,” he explains, “apoptosis being cell death.” Jesu! I’ve known about apoptosis for years!

 

Then the Duke tells me something I did not know and am not happy to hear: That there is no immediate result. That the out-working of apoptosis [the IMRT effect] will stretch out, continuing for a number of months into the future, often as much as a year,

 

What about continuing Avodart? I have a feeling that I should. And the Duke says, yes, absolutely continue. Why? Important to retard transition of testosterone into dihydrotestoseterone. And, Important to monitor  inflammation to keep it down. So for once, it's a situation where PSA really does count.

 

Back home, Jeanne is totally exited when she tells me, “The reduction in blood flow was amazing. The right side of the last color Doppler image was a rat’s nest of blood flow—so many blood vessels, all criss-crossing and jammed together. And now that entire side showed only a trace of red here and there. The difference was incredible!”

 

Still, we need a final PSA reading. If it follows pattern, it should now be well under five.

 

Two days later I received the Duke’s summary: The volume of the tumors was dramatically reduced: Before treatment, the right lobe tumor was 22 x 17 mm; after treatment it was down to 14 x 11 mm. The shadowy area on the left lobe which was 27 x 23 mm before treatment, had shrunk to 15 x 13 mm. [The lesions were also markedly reduced in size.] Pretty dramatic results, I thought, from such non-invasive treatment.

 

Here’s how the Duke summed up his test findings: “A significant decline of tumor volume involving both the right and left lobes. Significant  reduction of micovascular density (Now 1+ grade, where it was 3+ before) .  Reduced tumor neovascularity .(Another way of saying the same thing). . . Significantly declining trend of his PSA . . .”

 

But then the Duke knocked the wind out of me with this: “I clearly told Mr. Blum that we may not see a full radiation effect soon after finishing the treatment. It may take months, if not a year.” Then he advised monitoring my PSA, adding, “It will be satisfactory if his PSA nadir reaches 1.0 or under.”

 

So it’s far from over! I suppose I had half-expected the damn cancer to shrivel up and disappear. Hardest to accept was the fact that I will probably not know how effective the IMRT has been for an entire year, maybe longer. What I do know for damn sure is that I can’t get additional IMRT. Not to the same tissue. The tissue targeted has received its maximum tolerable lifetime dose.

 

So what to do? Eat good food. Continue with Avodart.  Get regular exercise. Avoid sugar and anger since according to Traditional Oriental Medicine, cancer is an angry disease. And anger and sugar feed cancer.

 

Then this disappointment: Turns out my PSA hasn’t budged. It’s still at 9.5 where it was six weeks ago. And it didn’t reassure me to learn that the Duke doesn’t want to see me for at least six months. A year of living with uncertainty. With the jury still out.